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Air pollution could be contributing to twice as many deaths as previously estimated, according to research published in the European Heart Journal. Cardiovascular disease often deals the final blow, with CVD events accounting for 40 to 80 percent of these deaths.

The updated estimates used hazard ratios from the Global Exposure Mortality Model, which was based on an “unmatched” number of international studies, and applied those ratios to air pollution data across Europe.

Overall, lead author Jos Lelieveld, PhD, and colleagues found ambient air pollution causes 790,000 deaths across Europe annually, including 659,000 in the 28 countries of the European Union. They also calculated 8.8 million people die globally each year because of air pollution, nearly double the previously estimated 4.5 million.

“To put this into perspective, this means that air pollution causes more extra deaths a year than tobacco smoking, which the World Health Organization estimates was responsible for an extra 7.2 million deaths in 2015,” co-author Thomas Münzel, MD, cardiologist with the University Medical Centre Mainz in Germany, said in a press release. “Smoking is avoidable but air pollution is not.”

Globally, Lelieveld et al. attributed air pollution to 120 extra deaths each year per 100,000 people. In Europe, however, that figure jumped to 133 deaths per 100,000 population, including more than 200 deaths annually per 100,000 people in eastern European countries.

The average annual limit for fine particulate matter in Europe is 2.5 times the amount recommended by the World Health Organization, and some European countries still exceed that upper limit.

“The high number of extra deaths caused by air pollution in Europe is explained by the combination of poor air quality and dense population, which leads to exposure that is among the highest in the world,” Lelieveld said in the release. “Although air pollution in eastern Europe is not much worse than in western Europe, the number of excess deaths it caused was higher. We think this may be explained by more advanced health care in western Europe, where life expectancy is generally higher.”

Lelieveld and co-authors said pollution’s link to ischemic heart disease and stroke is well-established, but fine particulate matter also may contribute to vascular impairment and related conditions such as hypertension and diabetes.

“There is still little mention of air pollution as a risk factor in the European and American guidelines on health care and disease prevention,” the researchers wrote in the journal. “While the clinical practice guidelines of the European Society of Cardiology indicate that air pollution can adversely affect cardiovascular health, we propose to additionally include recommendations on the mitigation of risks by individuals, organizations or governments.”